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Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply.
- A. 7 cm x 3 cm x 1 cm stage II decubitus noted on left shin.
- B. 40 u SSRI administered to cover capillary glucose of 160 mg/dL.
- C. Dose of 0.5 mg hydromorphone administered and the client feels better.
- D. 4 Maalox 5 mL PO administered pc as requested for c/o heartburn.
- E. Spouse voiced understanding of home urinary catheterization QID.
Correct Answer: A
Rationale: Metric units (A), decimal doses (C), and QID (E) are clear and acceptable. 'u' (B) risks confusion with '0,' and 'pc' with 'c/o' (D) are ambiguous, per safety standards.
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A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?
- A. Allow the child to stay home when the child seems anxious
- B. Call the teacher to get the child’s schoolwork to do at home
- C. Have the child attend school, starting with a few hours a day
- D. Sit with the child in the classroom whenever possible
Correct Answer: C
Rationale: Gradual exposure to school, starting with partial attendance (C), helps desensitize the child to separation anxiety. Staying home (A) reinforces avoidance, schoolwork at home (B) delays reintegration, and parental presence (D) hinders independence.
The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.
- A. I am going to join a walking program to lose excess weight.
- B. I may have dry mouth as a side effect from the oxybutynin.
- C. I really need caffeine to get myself going in the morning.
- D. I should perform Kegel exercises several times daily.
- E. I will void every 2 hours until I am having fewer accidents.
Correct Answer: A,B,D,E
Rationale: Weight loss (A) reduces bladder pressure, oxybutynin’s dry mouth side effect (B) is correct, Kegel exercises (D) strengthen pelvic floor muscles, and scheduled voiding (E) prevents urgency. Caffeine (C) irritates the bladder, worsening incontinence, indicating ineffective teaching.
The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.